Scar Revision FAQs

I recently had an accident and have a very ugly scar. What can Dr. Lam do to help me?
It is always a good idea to meet with Dr. Lam in consultation first to determine whether anything can be done early on after your injury. Scar revision prior to 6 months following an injury is oftentimes too early to intervene. In most cases, scar revision prior to a year following your injury can also be too early because some scars that look very bad early on almost completely fade away without any intervention after a year or more.The reason to meet with Dr. Lam early on after your injury is to discuss options to help your scar mature well so as to avoid a scar revision in the future. At times with a very bad scar or if the scar appears to be healing poorly, Dr. Lam will intervene prior to 6 months following an injury, but the likelihood that Dr. Lam will perform a formal scar revision prior to 6 months following an injury is rare. During the first 6 months to a year, Dr. Lam can help a scar heal better through a variety of methods. He will follow you carefully to make sure that the area does not thicken, which he will treat with a combination of injectables to reduce any unwanted hardness or fullness in the incision or near the incision. If the incision line stays red for too long, Dr. Lam will use his laser to lessen the undesirable redness. If the area becomes slightly darker due to excessive sun exposure during the first 4 to 6 weeks, then he may counsel you about skin bleaching products to expedite resolution of this temporary condition.

Does Mederma (onion extract), Strivectin, or Vitamin E oil work to help improve my scar?
Dr. Lam does not believe that any of these remedies work to help a scar mature well. In fact, rigorous scientific studies that have involved blinded, prospective, randomized, split scar analysis (in other words, good and controlled scientific research) have indicated that these treatments provide no improvement at all in an incision or scar. In fact, Vitamin E oil has been shown actually to worsen wound healing in some cases. In the past, Dr. Lam used Vitamin E oil to help with wound healing. However, with recent evidence to the contrary, he no longer believes that any of these topical ointments do any good to help with scar healing.

Will insurance cover my scar revision?
Dr. Lam does not accept insurance of any kind.

I have a scar on my body. Will Dr. Lam help me with my scar revision?In most cases, no. Dr. Lam specializes only in plastic and reconstructive surgery of the face and neck and will refer you to an appropriate body plastic surgeon who would help you with your situation. If your scar simply requires early treatment with injectables or laser therapy, he may elect to help you along until you may require the services of a body plastic surgeon for definitive surgical correction.

How does scar revision surgery work?To learn how scar revision surgery works, you must first understand what makes a scar visible. A scar is oftentimes noticeable because it is an obvious straight line that your eye can easily follow. One of the principles of scar revision is to transform that straight line into a complicated, irregularized line (see next question) so that your eye simply has a very hard time following that line even with close inspection. The second reason a scar is visible is that the scar is darker or lighter than the surrounding skin color. Dark color fades over time, whereas a light color incision line will most likely need to be removed and resutured following the good principles of scar revision. Third, a scar may be visible because the incision line or the area adjacent to it is depressed or raised, a so-called contour deformity. The scar will then have to be revised to minimize or eliminate this contour problem. Another reason that a scar is unfavorable in appearance is that the scar tethers a nearby structure either all the time or only when you move your face, e.g., restricting or tethering the lip, the nose, or the eyelids. Sometimes a scar must be reoriented or lengthened in order to eliminate this problem (see z-plasty below for example).

Will my scar look better immediately after scar revision?Actually, your scar will most likely look worse initially after scar revision. In most cases, when you come to see Dr. Lam your scar has already faded to a large extent and looks much better than when you just sustained the injury. However, Dr. Lam must not only make that incision line look fresh again but take a straight line and make it irregular so that it becomes more obvious initially but less visible only over time, i.e., much later in time. Initially, the repair will be quite visible and may remain so for many months thereafter. Oftentimes, the scar does not look considerably better for even a year afterwards, especially in Hispanic, Asian, and darker skin types that tend to maintain redness or darkness along the incision line for many months following the scar-revision procedure.

What are some options for scar revision that Dr. Lam can use for me?There are many options for scar revision, which Dr. Lam will suggest to you based on the nature of your scar. Only after a formal consultation with Dr. Lam will you be able to understand which option(s) are the most suitable in your situation. The following is a review of some of the basic types of scar revisions that Dr. Lam uses to transform a straight line that is very visible to the naked eye into a complex, irregular line that is much harder for the eye to see. Geometric Broken-Line RepairGeometric broken-line repair (GBLR) is perhaps the Rolls Royce of all scar revisions. The principle of GBLR is to make an irregularly irregular pattern so that your eye has the hardest time following the incision line and thereby makes the incision virtually undetectable. Using precise and randomly alternating squares, rectangles, triangles, and trapezoids that measure between 3 to 5 mm and that interlock with one another (as illustrated), the scar is transformed from a straight line into a very difficult to follow micro zig-zag appearance. Oftentimes for the best results Dr. Lam will follow a GBLR with mechanical dermabrasion about 6 to 8 weeks following the procedure (see response to next question for details regarding mechanical dermabrasion).This gentleman underwent a mid-forehead browlift elsewhere leaving him with white scars that were visible from even a social distance necessitating him to wear his hairstyle a certain way. He is shown a year and a half after geometric broken line scar revision and one session of mechanical dermabrasion. It is very hard to detect the scar even at close range.Multiple Z-plasty
A z-plasty involves redirecting the forces of tension and also lengthening a contracted or shortened scar. By irregularizing a straight line, it also serves to make it more difficult to see the scar and thereby camouflage it. The other major benefit of a z-plasty is that it is perhaps the most tissue sparing. In areas where tissue distortion would arise from removal of too much tissue, the z-plasty is the preferred treatment. Oftentimes, Dr. Lam uses a combination of scar revision techniques depending on the area of the face and what kind of scar is present.
W-plasty
The w-plasty like the z-plasty serves to irregularize a straight line and break up contractile forces but does not lengthen or redirect the forces of tension like a z-plasty does. The w-plasty works well to make it difficult to see a straight line but does not lengthen the incision like a z-plasty does, which at times may be more desirable.

Are there any options for me to make my scar look better without real surgery?
Yes, there are. If your scar is only mildly visible or there is a mild contour deformity at the edges of the incision, mechanical dermabrasion can be used to sand down the areas to make the area flatter and the incision line less visible. In fact, Dr. Lam oftentimes uses mechanical dermabrasion following a formal scar revision approximately 6 weeks after the procedure in order to enhance the result. Mechanical dermabrasion employs an instrument equipped with a wire-brush spinning at 35,000-rpm that can precisely remove the outer layer of skin. The recovery time is similar to a physician-strength chemical peel or plasma resurfacing, i.e., about a week. You must also remain out of prolonged sun exposure for about 6 weeks following treatment. Instead, if you notice a slight depression to the scar, wire subcision can release any tethering of the scar to the deeper tissues. Alternatively, silicone microdroplets can be used to raise areas of depression.

I have keloids that have occurred in my body. Does that prevent Dr. Lam from performing a scar revision on my face?
First of all, it is important to distinguish between a frank keloid and what is known as a hypertrophic scar. A keloid is a scar that is so enlarged that it extends beyond the borders of the scar. A hypertrophic scar, on the other hand, is simply a very thickened and maybe slightly widened scar. Both conditions can respond to steroid and 5-fluoruouracil (5-FU) injections to reduce their bulk. However, oftentimes the first treatment measure is to excise them followed by aforementioned injections as necessary (see next question).Further, real keloids are almost unheard of on the face. The face is defined as the area in front of the ears and not involving the scalp and the neck. The areas where keloids are often distributed include the earlobes after ear piercing, the neck after shaving, and the back of the head after hair trimming and most often are found in African-Americans or darker complected races. Keloids manifest and may continue to grow after a very minor insult like an ingrown hair or after shaving. Hypertrophic scars usually arise from a real injury of some kind and tend not to continue to grow.Remember two facts. First, keloids are almost unheard of in the face proper even if you may have keloids on other parts of your body or in the neck/scalp/earlobes. Second, the scar revision technique is a very precise plastic surgical closure, which is different from the rough injury that you may have sustained to lead to a hypertrophic scar or keloid on the body. For these reasons, even if you have a keloid or hypertrophic scar on the body, you may very well still be a good candidate for facial scar revision.

How does Dr. Lam treat keloids?
Please read the response to the previous question to understand what makes a keloid different from a hypertrophic scar. A keloid is treated very differently. Simple excision and meticulous closure after removal of a hypertrophic scar may be sufficient. However, simple excision and closure after removal of a keloid is almost never adequate. Serial steroid, 5-FU, and bleomycin injections are often necessary to control and to minimize re-expansion of a keloid. Without these follow-up treatments, your keloid may grow even larger than before Dr. Lam’s excision of it. As the histological architecture of a keloid exhibits collagen disarray, silicone sheeting and silicone gels should be applied daily to realign the collagen bundles by virtue of the electrostatic properties of the silicone. In addition, ongoing pressure dressing to the affected area can also minimize regrowth. If these conservative measures fail, low-dose radiation therapy may need to be performed to provide more definitive control. Because Dr. Lam believes that most conservative therapies fail, Dr. Lam advocates use of timed excision or the keloid with low-dose radiation to start within 24 hours for a period of 5 days to attain oftentimes a success rate of over 95%.

I have acne scarring. How can Dr. Lam help me?
In the past, Dr. Lam used mechanical dermabrasion to manage acne scarring. However, he believes today that dermabrasion (not to be confused with microdermabrasion) does not offer sufficient improvement to be warranted in most cases. The major pathology in acne scarring is a depressed scar. Traditional dermabrasion tries to level the field by lowering normal skin down to the level of the abnormal skin. Instead, Dr. Lam believes it is important to elevate the depressed scar to the level of the normal surrounding skin. The way in which Dr. Lam accomplishes this task depends on the problem at hand. For small pits and depressions, he uses what he calls the CROSS technique which elevates the microscars up toward normal skin tissue levels using a series of very concentrated micro-acid treatments. He has used this technique safely in skin types, including Hispanic, Middle Eastern, and East Asians without loss of skin color or scarring, having performed hundreds of procedures to date. In wider areas of depression, Dr. Lam uses microdroplets of silicone to elevate these depressed scars and to bring the atrophied (depressed) tissues up toward the level of normal skin.